Week Four: Centered SOAP Notice and Affected person Case Presentation
School of Nursing-PMHNP, Walden College
NRNP 6665: PMHNP Care Throughout the Lifespan 1
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Introduction
A person’s psychiatric examination ought to be full and built-in.
essential within the improvement of an accurate psychiatric prognosis Information have to be gathered from
quite a few sources with out bias with a purpose to obtain dependable information. The aim of this
task is to achieve an understanding of vital inquiries to ask throughout an Assessment and
methods to successfully assess and diagnose a temper dysfunction based mostly on data acquired from the
affected person and goal data obtained throughout an interview by the PMHNP. After
interviewing the affected person, the Assessment was famous, and three differential diagnoses have been
developed based mostly on the data gathered through the interview session. A PMHNP was
referred to a 26-year-old White feminine affected person for therapy and continued administration of her
psychological well being drawback.
CC: “I’ve a historical past of taking drugs and stopping them; I believe the remedy squashes
who I’m”.
HPI: J.P a 26-year-old White feminine who got here in for remedy administration. Affected person
is at present taking Zoloft which she complains made her excessive when she is inventive and whereas
sleeping her thoughts will probably be racing. She additionally takes Risperidone which made her acquire weight. Takes
Seroquel which made her acquire weight as nicely, Klonopin, she complained it slowed her down.
Due to the above listed discomfort and negative effects affected person listed, affected person stopped taking the
remedy.
Substance Historical past or Present use: Nicotine: smoke a few pack cigarette a day and can
not stop. Alcohol: admits to consuming alcohol however that was 19 years in the past. Used marijuana some
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years in the past and bought paranoid, stopped smoking it. Cocaine and different stimulants: denies use.
Caffeine: denies. Sedatives: Denies. Denies use of mushrooms. Denies use of ache tablets or avenue
medicine. Denies use of any kind of ecstasy medicine.
Household Psychiatric: Mom had bipolar, Father was arrested and had jail time in jail as a result of
medicine for 10 years now. Brother has schizophrenia however by no means went to hospital for therapy. No
household historical past of suicide. Affected person admits that she tried to kill herself as soon as prior to now however I will not
do it once more.
Psycho-social Historical past: Lives: lives together with her mom and generally her boyfriend. Goes over to
her mom if her boyfriend’s will get mad at her for sleeping round. Work: employed; works with
aunt’s bookstore. Misses work when she is feeling low. Training: at school for cosmetology to
do make up for film stars. Enjoyable actions: writing her life story, paints Picasso. Arrest: police
picked affected person up and took her the hospital that she was discovered dancing bare. Trauma: Father
was fairly powerful and yelled at them rather a lot. Raised by mom and older brother.
Hospitalization: Affected person have been admitted 4 occasions. Admitted for suicide
ideation: overdosed with Benadryl in 2017. When affected person was a young person, went for some days
with out sleeping. They gave affected person some remedy within the hospital that she will’t keep in mind the
title.
Psychiatric Historical past: Melancholy, Nervousness, Bipolar. Melancholy: get depressed for about Four to five
occasions a yr; when affected person doesn’t have any power or creativity then affected person feels depressed and
not need to do something. Throughout these episodes, are occasions when affected person doesn’t take her
remedy. Affected person denies being having anxiousness presently. Denies repetitive episodes or OCD.
Denies AVH/Delusions. Solely hallucinates when she just isn’t sleeping nicely; she hears voice. However
none presently. Urge for food: when inventive she is simply too busy to eat, when she is crashing, she eats a
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lot. Unhealthy desires: denies unhealthy desires. Sleep: 5 to six hours. When inventive sleeps for three hours a
week. When crashing can sleep for 12 to 16 hours a day.
Present Remedy: Zoloft, Risperidone, Seroquel, Klonopin, being pregnant management capsule
Allergy symptoms: NKDA
Reproductive Historical past: affected person is sexually energetic. Affected person states that she likes to have numerous
intercourse and it makes her really feel excessive. Takes contraception capsule for PCO. Her contraception is common
kind.
Medical historical past: Hypothyroidism, PCO
ROS:
GENERAL: feeling heat, no chills, no fatigue
HEENT: Eyes: Imaginative and prescient intact, yellow sclerae. Ears: constructive earache, constructive exhausting of listening to,
Nostril: denies runny nostril, sneezing, or congestion, Throat: no sore throat.
SKIN: Heat to the touch, No rash
CARDIOVASCULAR: No chest ache, No palpitations, or edema.
RESPIRATORY: No shortness of breath, unfavorable for cough or hemoptysis
GASTROINTESTINAL: Occasional constipation, No nausea, vomiting, or diarrhea. No
stomach ache, no blood stool
GENITOURINARY: denies any drawback with urination or bladder
NEUROLOGICAL: frequent headache, no syncope, numbness, or tingling within the extremities.
MUSCULOSKELETAL: occasional ought to and again ache, No muscle, joint ache, or stiffness.
HEMATOLOGIC: No anemia or bleeding dysfunction
LYMPHATICS: No enlarged nodes.
PSYCHIATRIC: a historical past of bipolar, despair
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ENDOCRINOLOGIC: No experiences of sweating, chilly, or warmth intolerance. No polyuria or
polydipsia.
Diagnostic outcomes: No diagnostic take a look at or labs wanted through the session
Assessment
Psychological Standing Examination
J.P. is oriented 4 occasions. Through the interview, you will need to be capable to accurately reply
questions, comply with orders, and stay alert. She can also be good and neurologically sound. Her temper
is balanced however dysthymic. She responds to all questions and goes into nice depth when
obligatory. Though there have been no acute psychosis or temper signs, the affected person appeared
involved. Denies any present or earlier historical past of suicide. Denies having any homicidal concepts
or listening to voices or ideas which may trigger hurt to individuals. Your whole reminiscences are nonetheless
intact.
Diagnostic Impression
Bipolar Dysfunction: The next prognosis relies on the data provided and is topic
to alter as new information turns into accessible throughout later classes. Bipolar dysfunction also referred to as
manic-depressive sickness or manic despair, is a psychological situation that causes erratic temper
swings, power, exercise ranges, focus, and the flexibility to carry out every day chores. Individuals with bipolar
sickness have occasions of exceptionally excessive temper, adjustments in sleep patterns and exercise ranges, and
unusual actions, which they do not all the time acknowledge as dangerous or undesired. The time period “temper
episodes” refers to those separate intervals (Bachem & Casey, 2018). To be identified with a
bipolar dysfunction, a person should meet particular standards, in response to the DSM-5. Inside two
weeks, the affected person should expertise 5 or extra of the next signs: A definite time of
abnormally and persistently excessive, expansive, or irritable temper, in addition to abnormally and
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persistently heightened exercise or power, that lasts no less than Four days and is current just about each
day (American Psychiatric Affiliation, 2013). Our affected person J.P offered with signs and
conduct that correlates with the above listed signs: affected person states that she get depressed
for about Four to five occasions a yr; when affected person doesn’t have any power or creativity then affected person
feels depressed and never need to do something. Throughout these episodes, are occasions when affected person does
not take her remedy. Affected person states that she likes to have numerous intercourse with completely different individuals,
although she has a boyfriend, that it makes her really feel excessive. Affected person smoke a few pack cigarette
a day, stated she is planning to stop. Admitted for suicide ideation: overdosed with Benadryl.
Sufferers works in her aunt’s bookstores however can keep away as she likes she doesn’t really feel prefer it.
Borderline Character Dysfunction: Borderline Character Dysfunction is a serious psychological well being
situation with no acknowledged etiology. People with Borderline Character Dysfunction have
steady temper swings, self-image points, impulsive conduct, and hassle referring to others,
even animals (Sadock, et al., 2015). A sample of adjusting moods, self-image, and conduct
characterizes borderline character dysfunction. Impulsive conduct and relationship points are
widespread outcomes of those signs. Anger, despair, and anxiousness can persist anyplace from a
few hours to days in individuals with borderline character dysfunction. In accordance with the DSM-5, the
affected person should have skilled these signs for no less than 6 months: disabling episodes of anger,
despair, and anxiousness that final for hours or days, issues controlling anger, issue trusting,
irrational worry of different individuals’s intentions, emotions of dissociation, and emotions of vacancy;
intense episodes of anger, despair, and anxiousness that final for hours or days; issues
controlling anger, issue trusting, irrational worry of different individuals’s intentions, emotions of
dissoci (American Psychiatric Affiliation, 2013). The above-listed signs are evident in J.P
our affected person as evidenced by affected person get depressed for about Four to five occasions a yr; when
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affected person doesn’t have any power or creativity then affected person feels depressed and never need to do
something. Throughout these episodes, are occasions when affected person doesn’t take her remedy. Affected person
states that she likes to have numerous intercourse with completely different individuals, although she has a boyfriend,
that it makes her really feel excessive. Affected person smoke a few pack cigarette a day, stated she is planning
to stop. Admitted for suicide ideation: overdosed with Benadryl. Sufferers works in her aunt’s
bookstores however can keep away as she likes she doesn’t really feel prefer it.
Generalized Nervousness Dysfunction:
Reflection
CBT therapy advice
Case Formulation and Remedy Plan
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